Failure to Accommodate Resident's Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's documented food preference for boiled eggs each day. The resident, who has diagnoses including cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety, was assessed as moderately cognitively impaired with a Brief Interview for Mental Status score of 8 out of 15. The resident's face sheet and tray ticket both indicated a preference and instruction for boiled eggs daily. However, during multiple observations and interviews, the resident reported not receiving boiled eggs for breakfast, and surveyors confirmed that the breakfast trays did not contain boiled eggs on those occasions. The dietary manager acknowledged awareness of the resident's preference, stating that the information was obtained through direct communication with residents and recorded on meal tickets. Despite this, the dietary manager admitted that boiled eggs were not consistently provided, citing supply issues and a lack of regular ordering. The deficiency was discussed with facility leadership, but no additional information was provided prior to the survey exit.